Many opioid addicts describe their first experience with opioids as "getting right", not "getting high". We have known for a long time that many people are born with lower than normal natural opioid production, and pain pills and opiates are their way to balance themselves out.

This week (May 15, 2017), the Atlantic's Olga Khazan published an article highlighting the connection between pain, depression and opioid abuse. While there have been a number of one-off journal articles on different aspects of the relationship between mood disorders and opioid abuse, her article is the first that we have seen that pulls them all together into a coherent argument.

Her main thesis is that a combination of three factors drive those with depression to abuse opioids:

Dopamine system--The natural system of the brain that releases endorphins (e.g. runners high) to make us feel good, is less active in those with depression

Pain--Depression makes people more sensitive and less able to tolerate pain

Opioids--Opioids relieve the feelings of depression, at least temporarily

People with acute conditions do not seek opioids any more than the rest of the population, and those with chronic pain are only marginally more likely to initiate opioid therapy, but once exposed, they are more than 2x more likely to continue longer on their pain pill prescriptions. And not just continue, depressed people are also more than 2x more likely to abuse their prescriptions.

Sadly, over the long-term opioids actually have an increased association with new-onset depression. According to Scherrer et al:

. . .opioids may cause short-term improvement in mood, but long-term use is associated with risk of new-onset depression.

— Scherrer et al, Annals of Family Medicine, February 2016

Clinically, we see other associated issues. When people come to MATClinics and start on their buprenorphine treatment, they sometimes report increased feelings of depression and anxiety. Partly that can be explained by the nature of buprenorphine. Replacing pain pills or heroin with a partial agonist kills cravings and helps patients avoid withdrawals, but there is no associated "euphoria", or mood changing effect. Its not a surprise that those with underlying mood disorders might find those feelings coming to the surface.

We have found that many of our patients are in need of mental health counseling to help them address the underlying issues that are driving their depression and anxiety. Substance abuse counseling is important, but cannot replace broad based mental health counseling. Patients will be much more successful in fighting their addiction if they are also effectively controlling underlying challenges to their mood.